Upload
voxuyen
View
222
Download
4
Embed Size (px)
Citation preview
Cherokee Nation Health Services
Strategic Objectives & Quality Improvement
Plan
FY 2009
Approval:
Group Leader, Health Services Date
Principal Chief, Cherokee Nation Date
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 1 of 48
CHEROKEE NATION HEALTH SERVICES 2009 STRATEGIC OBJECTIVES & QUALITY IMPROVEMENT PLAN
I. THE PLANNING FOUNDATION: CHEROKEE NATION DECLARATION OF DESIGNED PURPOSE 1-5
VISION 1 MISSION 2 IDENTITY STATEMENT 3 DESIRED OUTCOMES 3 GUIDING PRINCIPLES 3 ATTRIBUTES 4 GOALS & OBJECTIVES 5
II. CHEROKEE NATION HEALTH MISSION & VISION 5
III. QUALITY IMPROVEMENT PLAN & PERFORMANCE MONITORING 5-10
SPECIFIC PURPOSE OF THE PLAN 5 SCOPE OF ACTIVITIES 8 ORGANIZATION 9 METHODOLOGY 10
IV. THE CONCEPTUAL STRUCTURE OF THE BALANCED SCORECARD 11
V. OVERVIEW OF HEALTH SERVICES 2009-2013 STRATEGIC PRIORITIES 13
VI. 2009 HEALTH SERVICES SCORECARD OBJECTIVES BY PRIORITY AREA 14-23
COMMUNITY-BASED HEALTH PROMOTION 17 HEALTH OUTCOMES FOR CHEROKEE COMMUNITIES 17 PUBLIC HEALTH INFRASTRUCTURE 19 ACCESS TO SERVICES 20 RESOURCE MANAGEMENT 21 HEALTH INDUSTRY BUSINESS LEADERSHIP 21 OPERATIONAL EFFICIENCY 22 CHEROKEE WORKFORCE DEVELOPMENT 23
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 2 of 48
VI. 2009 BALANCED SCORECARDS 24-45
OVERALL HEALTH SERVICES SCORECARD 25-31 DIRECT CARE SCORECARDS 32-34 CLINICAL SUPPORT SCORECARDS 35-39 COMMUNITY HEALTH SCORECARDS 40-43 ADMINISTRATIVE SUPPORT SCORECARDS 42-43
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 3 of 48
CHEROKEE NATION HEALTH SERVICES 2009 STRATEGIC OBJECTIVES & QUALITY IMPROVEMENT PLAN
I. THE PLANNING FOUNDATION: CHEROKEE NATION DECLARATION OF DESIGNED PURPOSE1 The Cherokee Nation Declaration of Designed Purpose is a 100- year strategy document
developed in 2001 to provide a clear understanding of where the Cherokee Nation needs to
go in the next 100 years and how to get there. Perhaps the first question we must ask is "Why
do we have a Cherokee Nation?" The simple answer is that the Cherokee Nation and its
history and culture are a legacy that enriches our lives, families, and community. It gives us
strength in times of challenge, it gives us comfort when we are weak and it gives us a sense of
identity and value. It sustains us and gives us direction. It outlines our "designed purpose".
This Declaration is the plan to further our legacy, that in 100 years we will have decedents
that joyfully and gratefully receive that legacy, individually and as a Nation, to face adversity,
survive, adapt, prosper, and excel.
Cherokee Nation Vision:
What will the Cherokee Nation look like in the future?
The Vision for the Cherokee Nation includes achieving and maintaining an enriching cultural
identity, economic self-reliance, and a strong government. The vision begins with sight of the
past. One hundred years ago, the Cherokee Nation had a sophisticated government with a
Supreme Court Building, National Capitol, penitentiary, nine court houses, an outstanding
educational system with two higher education institutions, one hundred fifty day schools,
and 90 percent literacy in the Cherokee language.
How could a society improve on a system where there was no poverty, every family had a
home and the government had no debt? It is part of the vision for the next one hundred years
to achieve what we had one hundred years ago: no poverty, every family having a home, and
11. Cherokee Nation Declaration of Designed Purpose - Yesterday, Today, and Tomorrow; Principal Chief Chadwick “Corntassel” Smith
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 4 of 48
the Cherokee Nation having no debt. In many ways, we want to repeat the success of our past
and use our cultural values to guide us in the future. The vision for the future of the Cherokee
Nation does not have to be distant, vague, or abstract. It is as present and concrete as one's
own life. The vision is "ga du gi" -working together - and its results. The vision focuses on
Cherokees becoming satisfied with their own personal achievement, fostering happy
functional families, strong and supportive communities, and a vibrant enduring tribal
government
The clarity of this vision is recognized when Cherokees have the careers they chose, the
ability to wisely determine their own destiny, families that enjoy the presence of and share in
the challenges of each member, communities that Cherokees genuinely desire to return and
enjoy, and a tribal government that Cherokees can take pride in and warmly contribute to.
The vision is achieved when we as citizens of the Cherokee Nation, motivated and driven by
our culture, enjoy each day of our short tenure in this world. This is a more detailed Vision of
the Cherokee Nation, which includes both the government and the people:
1. The Cherokee people shall enjoy and exercise an enriching cultural identity and lifeways
which includes a thriving command of our language, cultural history, art, traditions,
wisdom and lifeways
2. Cherokees and their government become economically self-reliant and sufficient to the
extent the Cherokee Nation is not required to accept federal funds to meet the needs of
its people and every Cherokee has the opportunity to pursue the career of his or her
choice.
3. The government of the Cherokee Nation becomes and maintains itself as a strong
sovereign government which protects the Cherokee people.
Cherokee Nation Mission:
How we will create value in the lives of our fellow citizens?
The Mission of the Cherokee Nation describes our primary purpose. Every part of the Tribe
should be designed to achieve this overall purpose. The mission identifies our distinctive
abilities. The Mission of the Cherokee Nation is "ga du gi": working together as individuals,
families, and communities for a quality of life for this and future generations by promoting
confidence, the tribal culture, and an effective sovereign government.
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 5 of 48
Cherokee Nation Identity Statement:
How will we define ourselves?
The identity statement of the Cherokee Nation is who we are and how we identify ourselves
as a Tribe. The government of the Cherokee Nation acknowledges that Cherokee identity has
been formulated over time and consists of shared patterns of behavior that include language,
ceremony, customs, values, beliefs, traditions, wisdom and knowledge, along with other
tangible and intangible forces, that combined are referred to as the Cherokee lifeways or
culture.
Cherokee Nation Desired Outcomes:
What do we want to become?
The Desired Outcomes for the Cherokee Nation state what the Tribe wants to achieve overall.
Our success is measured in terms of meeting the needs of the tribal members.
1. Exercise Sovereignty - A self-sufficient nation with an independent economic base,
protection, preservation, and promotion of sovereignty
2. Achieve Operational Performance - Specific operational performance benchmarks and
improvement for each operating team
3. Build Cherokee Nation Employees - A skilled, Cherokee value- oriented, satisfied,
friendly, and team-oriented workforce
4. Encourage Tribal Members -Active, involved, safe, healthy, stable, and economically
independent citizenry
5. Use Culture/Knowledge - Strong language, history, and culture, both individually and in
the delivery of services
Cherokee Nation Guiding Principles:
What will we use as guidance in making all of our decisions?
The Guiding Principles for the Cherokee Nation direct and support the decisions that drive the
behaviors, feelings, and attributes necessary to achieve the desired outcomes. Our guiding
principles must be thoughtfully determined since good principles will lead to good decisions
and good performance. The guiding principles and beliefs define how we intend to act in the
pursuit of our vision and mission.
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 6 of 48
• OUR SPIRIT -We believe that the Creator has a great design for us and acknowledge that
every Cherokee is part of the ever-renewing, ever-expanding, upward progressive
movement of life
• OUR STRENGTH- We will incorporate Cherokee culture by integrating language, history,
custom, wisdom, art, music and traditional values into everyday activities.
• OUR PEOPLE- We will build confidence and capability in individuals, families,
communities, and our government. We will inform and educate our people so that they
can make wise choices.
• OUR GOVERNMENT - We will act with openness, integrity, fairness, and respect for others.
We will make decisions that will be strategically driven. We will help our people to
attain their basic needs with available resources in a friendly, timely, positive, and
constructive manner. We will invest our resources in Cherokee communities to advance
the survival and growth of the Cherokee Nation
• OUR ENVIRONMENT- We will provide opportunities for all Cherokees and friends to
contribute to the welfare of the Cherokee Nation
• OUR SOVEREIGNTY- We will promote economic self-reliance. We will protect our
governmental rights of sovereignty
Cherokee Nation Attributes:
What do we hold valuable?
The attributes of Cherokee Nation employees largely drive the results of the Tribe. We can
influence and shape the behaviors and thereby influence outcomes.
• Respectful- each other hold the existence of everyone sacred
• Committed- never quit, no end or finish
• Cherokee Way of Life- preserve, use, teach, and learn the Cherokee language, history,
arts, wisdom, music and heritage
• Creative- think and give birth to ideas
• Integrity- honest, straight-forward, up-front and fair
• Leadership- train, teach, and motivate others - be an example, show initiative, set
direction, solve problems, make sound decisions
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 7 of 48
• Communicate-give and receive communication, ideas, criticism and information
• Self-Confident- with training and experience, we feel confident that we can make good
choices and implement them
• Cooperative - no territorialism; bend over backward to help
• Responsible - do what is right in all that you do
Cherokee Nation Goals & Objectives:
What must we improve and what must we keep?
The goals and objectives for each of the divisions identify milestones in moving toward the
desired outcomes. They drive behaviors, feelings, and attributes toward the desired
outcomes over the long term. Goals should be "SMART" - Specific, Measurable, Achievable,
Related to the mission, and Time-bound.
II. CHEROKEE NATION HEALTH MISSION & VISION:
Cherokee Nation Health Services Mission
• We are dedicated to working with our communities, families, and individuals to
promote and improve their health
Cherokee Nation Health Services Vision Statement
• The Cherokee people will achieve an optimal level of health resulting in healthy
communities for this and future generations
III. QUALITY IMPROVEMENT PLAN & PERFORMANCE MONITORING:
This Quality Improvement (QI) Plan is prepared in accordance with the Cherokee Nation
Health Services policy, “Quality Improvement and Plan Development Process," Governance
Manual, chapter 10. The plan will be carried out by the committee authorized in the policy,
“Committees with Governance Responsibilities,” Governance Manual, Chapter 4. The purpose
of this plan is to ensure that Cherokee Nation Health Services staff demonstrates a consistent
endeavor to deliver care that is optimal in an environment of minimal risk.
Specific Purpose of the Plan:
1. Continually and systematically plan, design, measure, assess and improve performance of
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 8 of 48
clinic and system-wide functions and processes relative to patient care and services. The
Cherokee Nation utilizes the Balanced Scorecard to measure its strategy and QI process.
Each department within Cherokee Nation begins developing the annual balance scorecard
by utilizing the five desired outcomes located in the Declaration of Designed Purpose and
the Cherokee Nation Health Services Strategic Plan for 2009-2013. The following
terminology describes the documents that Health Services uses to cascade its strategy into
the organization.
• Desired Outcomes: Goals of Tribe
• Health Services Long-Range Plan: Ten to fifteen year plan
• Health Services Scorecard: Three to five year plan for Health Services on how to achieve
desired outcomes outlined in the Declaration of Designed Purpose and the
Comprehensive Plan for Health Services
• Annual QI Plan/Scorecard: One year plan of how to achieve Health Services Scorecard
• Strategic Plan: Map of Strategic Plan and Supporting Goals for 2009-2013
2. Incorporates the Desired Outcomes as outlined in the Declaration of Designed Purpose
document of the Cherokee Nation into patient care and services.
3. Utilize goals that support the desired outcomes:
• Community Based Health Promotion – Promote healthy Cherokee Communities
through prevention, partnerships, and leadership development;
• Health Outcomes for Children, Families and Adults – Improve the quality of health
services and outcomes for Cherokee individuals, families, and communities;
• Public Health Infrastructure – Strengthen health surveillance, research, and policy to
improve health outcomes and promote partnerships;
• Access & Equity to Services –Increase access & achieve equity for appropriate health
services
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 9 of 48
• Resource Management – Increase revenue to health programs for Cherokee strategic
health priorities;
• Health Industry Business Leadership – Strengthen health industry business partnerships
in Cherokee Nation;
• Organizational Efficiency – Develop and implement processes to improve
organizational deficiency;
• Cherokee Workforce: Develop a Cherokee workforce through recruitment, retention,
and strategic capacity building
4. Focus upon what is performed throughout the health services network, and how well it is
performed. To facilitate this goal emphasis is placed upon “dimensions of performance.”
These dimensions of performance include, but may not be limited to:
• Efficacy of the procedure or treatment in relation to the patient’s condition;
• Appropriateness of the specific test, procedure, or service to meet the patients’ needs;
• Timeliness with which a needed test, procedure, treatment, or service is provided to the
patient;
• Effectiveness with which tests, procedures, treatment, and services are provided;
• Continuity of the services provided to the patient with respect to other services,
practitioners, providers, and over time;
• Safety of the patient and others to whom the services are provided;
• Efficiency with which services are provided;
• Respect and caring with which services are provided;
5. Assure the improvement process is system-wide, monitoring, assessing and evaluating the
quality and appropriateness of patient care and clinical performance to identify changes
that will lead to improved performance and reduce the risk of sentinel events.
6. Achieve and maintain improvements made in performance throughout Cherokee Nation
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 10 of 48
Health Services.
7. Ensure appropriate reporting of information to the Quality Council to provide it with the
information it needs in fulfilling its responsibility for the quality of patient care and safety.
8. Ensure necessary information is communicated among departments, services, programs
and clinics when problems or opportunities to improve patient care involve more than one
component of the health care network.
9. Identified problems are tracked to assure improvement or problem resolution.
10. Information from departments, services, programs, and clinics and the findings of discreet
performance improvement activities are used to detect trends, patterns of performance or
potential problems that affect more than one component of the health care network.
11. Evaluate and revise the Balanced Scorecard annually and as necessary.
Scope of Activities:
The Quality Improvement Program is tasked with developing, implementing and
continuously facilitating the annual Balanced Scorecard. The scope of the Quality
Improvement Program includes an overall assessment of the efficacy of performance
improvement activities, with a focus on continually improving care and services provided
throughout the Cherokee Nation Health Services. The program consists of the three focus
components as follows:
• Performance Improvement – An approach to the continuous study and continuous
improvement of the processes of providing health care services to meet the needs of
individuals and communities. Synonyms include continuous quality improvement,
continuous improvement, organization-wide performance improvement and total
quality management.
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 11 of 48
• Quality Assurance – A program for systematic monitoring and evaluation of various
aspects of a project, service or facility, to ensure standards of quality are being met.
• Quality Control – An aggregate of activities (such as design analysis and inspection for
defects) designed to ensure adequate quality, especially in manufactured products.
Organization:
To achieve fulfillment of the purpose, goals and scope of the Balanced Scorecard, the
organizational structure of the Quality Improvement process is designed to facilitate an
effective system of measuring, analyzing and improving the care and services provided
throughout Cherokee Nation Health Services.
• The Quality Council will receive ongoing reports, relative communications, and updates
of ongoing activities. The Chairperson of the Quality Council will be notified
immediately of sentinel events or other urgent communications as it pertains to patient
care and services.
• With the authority delegated by the Quality Council, the medical staff strives to improve
and assure the provision of quality patient care through the monitoring, assessment,
and evaluation of performance measurement and outcome.
• The medical staff provides effective mechanisms to monitor, assess, and improve the
quality and appropriateness of patient care and the clinical performance and
competency of all individuals with clinical privileges.
• The Group Leader of Health Services provides for resources and support systems for the
performance improvement functions related to patient care and safety. Resources may
be limited and may have an impact on outcomes.
• With designated responsibility from the Quality Council, Quality Improvement
Committees will operate as functional groupings of individuals in the organization who
meet to evaluate and improve specific processes, system or function within Health
Services. Quality Improvement Committees are comprised of departmental leaders,
medical staff, and those individuals designated from each department, as appropriate,
who may have the highest degree of knowledge regarding a given improvement
project.
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 12 of 48
• Each Quality Improvement Committee will be conducted as outlined in Chapter 4 of the
Governance Manual. Minutes will be kept of each meeting, along with agendas and
sign-in sheets. These will be submitted to the Quality Improvement Program for
tracking and reporting. Each Quality Improvement Committee will be required to
submit quarter reports to the Quality Council that outlines the progress of their
identified performance priorities and indicators.
Figure 1
Methodology:
The scientific method of performance improvement chosen by Health Services is the Plan, Do,
Check and Act method (See Figure 1). Methodology will also comply with accreditation
standards as outlined by the Accreditation Association for Ambulatory Health Care (AAAHC),
Commission on Accreditation of Ambulance Services (CAAS), and the Commission on
Accreditation of Rehabilitation Facilities (CARF). The following characteristics will be evident
in the annual Balanced Scorecard:
1. Identify important problems, concerns, and issues relevant to patient care, and services.
2. Evaluate trends in frequency, severity, and other potential issues.
3. Take corrective action to resolve identified issues.
4. Evaluate if corrective/planned actions have achieved measurable improvement.
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 13 of 48
IV. THE CONCEPTUAL STRUCTURE OF THE BALANCED SCORECARD
The Balanced Scorecard is not just a tool nor is it just a quality management project. Rather, it
is a dynamic, continual, and comprehensive strategic performance management system that
encompasses mission, strategy and perspectives (see Figure 2), which depicts the basic
design of the balanced scorecard, has been adapted to the Cherokee Nation strategic
priorities and the fundamental activities of Cherokee Nation Health Services.
The Balanced Scorecard Approach for Health
Develop & implement effective ways for health services to practice mutual
contribution, promote Tsalagi lifeways, develop leadership & build a healthy
workforce
Building capacity to implement strategy through training in mutual contribution, community health partnerships, &
knowledge of Tsalagi language & lifeways; exposure to planning tool; appropriate discipline-specific continuing ed
Targeting resources to strategic priorities; Accountability for efficient use of funds;
Employing business practices that support strategic priorities; Limit pursuit of external
funding to strategic health priorities
Employee Learning & Growth
Meeting Cherokee Health needs efficiently by cultivating community partnerships that produce long term value &
maintaining a highly-skilled capable workforce that values Tsalagilanguage & lifeways
Cherokee Citizen Perspective
Internal ProcessesFinancial Foundation Healthy people living in healthy communities, where citizens work
together to prevent & manage disease through mutual
contribution & practice of traditional Tsalagi lifeways
VISION
Figure 2
The mission is at the top of the model, signifying its importance as the main driver and
catalyst of activities in a public sector organization. At the core of the approach is the
business strategy, which is the means to accomplish the mission and nurture advancement
of the organization’s vision through a focus on goals and objectives. Connected to these two
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 14 of 48
components are the major organizational perspectives that are taken into account in the
balanced scorecard approach: customer, financial, internal processes, and learning and
growth. While perspectives may vary from organization to organization, most often these
four are included in Balanced Scorecard systems. This adapted model shows one perspective
being balanced by the others and all being driven by the organization’s mission, vision, and
strategy. Among the four perspectives, the views of individuals, families, and other
stakeholders provide insight into an organization’s ability to provide services that are of high
quality, accessible, effective, and satisfactory to the individuals utilizing the services. Internal
processes are viewed in light of the critical business processes that serve to meet the
organization’s performance expectations. An organization’s abilities to manage and adapt to
change through employees, information systems, and organizational design are reflected in
the employee and organizational perspective. The last perspective, the financial point of
view, provides an indication of an organization’s ability to meet the needs of the individuals
it serves efficiently and in a cost-effective manner, providing the best value for each dollar
spent. By adopting the Balanced Scorecard approach, organizational leadership embraces a
“vision for change” and nurtures a sense of team collaboration and dedication to strategy as
part of the organization’s transition to a new way of conducting its day-to-day work. It is
about making vision and strategy the center of an organization’s daily life and culture. Under
this framework the goals and objectives operationalize and serve as the means to accomplish
the mission within the context of the agency’s vision and values, while the measures reflect
progress toward attaining the goals. Further, the framework encourages the operating
divisions within the organization to align their initiatives and programs with the
organizational strategic plan and work toward a shared vision in a systematic and uniform
manner. As such, the balanced scorecard framework fosters a service environment that
promotes change, integrates several key perspectives, aligning organizational mission with
strategies to attain goals, and maintains the spotlight on attention to outcomes,
performance and results. Overall, the balanced scorecard approach provides a stronger
infrastructure for improved communications, ownership of results, and greater
accountability. Scorecard development occurs at three levels: Overall Health Services, Senior
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 15 of 48
Director Level, and program level. Figure 3 illustrates the cascading of scorecards
throughout the division.
ANNUAL HEALTH SCORECARD PROCESS
FY 2009 HEALTH SERVICES OVERALL SCORECARD
DIRECT CARE COMMUNITYHEALTH
CLINICALSUPPORT
ADMINSUPPORT
ClinicsWPMHCSHJCCRSHCWRHCTRHC
AMO HCBartlesville
Vinita
Community Health Promotion
BehavioralHealth
EMSJack Brown AdolescentTreatment
Center
Medical SupportPrograms
Clinical AdvisorsContract Health
Health PolicyQuality
Improvement
Health FinanceBilling
Health IS
Compliance & Medical Records
Planning & Dev
Legislative
Health Communications
Figure 3
V. Overview of Health Services 2009-2013 Strategic Priorities
The 2009-2013 strategic priorities build on the strengths of the 2001 Health Services Long
Range Plan. Celebrating our achievements since 2001 and carefully examining those areas
continuing to need focus. Recognizing that investigation of our successful methods and
processes will identify our “best practices”.
This section provides a brief overview of the priorities driving the 2009 planning process and
scorecard development. The priorities emphasize expansion and quality improvement of
services, access, and long-range planning to strengthen our role as a fundamental contributor
to the overall priorities of the Cherokee Nation - Jobs, Language, and Community. We
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 16 of 48
recognize the health status of communities impacts those priorities measurably and our
performance is reflected in the overall progress of the Cherokee Nation toward achieving our
mission. We acknowledge the methods of service delivery must also be consistent with the
strategies. We must examine our processes to ensure we practice mutual contribution,
Cherokee lifeways, and build a healthy and productive workforce.
Cherokee Nation Health has identified eight strategic priorities, the priorities are intended to
strengthen the structural integrity of the existing service system capacity and provide
targeted service system expansion where needed and supported by evidence. Each year the
strategic plan is reviewed and updated to ensure relevance. The 2009-2013 Cherokee Nation
Health Service Strategic Plan appears in Tables 1and 2 located on pages 15 and 16 of this
document.
VI. 2009 Health Services Scorecard Objectives by Priority Area
A Balanced Scorecard is developed and implemented on an annual basis. Health Services staff
participate in the development of the scorecard using the Balanced Scorecard methodology.
Utilizing the strategic priorities of Health Services, departments and disciplines develop
specific, measurable, achievable, relevant, and time-phased (SMART) annual objectives. The
objectives are developed by the staff and based on current knowledge, experience, and best
practices. Each year this plan is submitted to and reviewed by the Cherokee Nation Health
Services Quality Council for approval. Recommended changes are made and the plan is
submitted to the Principal Chief for final review and approval within the first week of the fiscal
year. The approved plan is then finalized and distributed to leadership for implementation.
This section describes objectives for each of Health Service’s strategic priority areas for 2009.
Objectives are presented in this manner to demonstrate our collective efforts as a group as
well as promote integration among the various programs and departments. Focusing on our
common objectives makes evident our commitment to ga du gi - working together - and
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 17 of 48
Table 1
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 18 of 48
Table 2
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 19 of 48
provides an opportunity to examine internal partnership possibilities to make the most of our
available resources.
Community-Based Health Promotion:
Cherokee Nation Health Services is a leader in community-based health programs from best
practice substance abuse prevention to nutrition and physical activity promotion. Activities
vary and are delivered via a variety of programs in collaboration with Cherokee Nation
programs such as Community Services, Human Services, Marshal Services, and Education. We
use the Socioecological Model of Health Promotion which emphasizes working on a variety of
levels within the community including individual, interpersonal, organizational, community,
and public policy. Our community programs are delivered practicing the mutual contribution
strategy realizing Cherokee Communities have the knowledge, skills, and human capital to
both guide and implement projects. We recognize our shared responsibility with
communities to build healthy future generations. Some highlights from community-based
objectives for 2009 include:
• FY 09 1.1a: Develop a written process for conducting community health assessments
• FY 09 1.2a: Develop a written plan for a Community Health Surveillance System
• FY 09 1.3a: Develop a definition & baseline number of community partnerships
• FY 09 1.4a: Develop a definition & baseline number of school partnerships
• FY 09 1.5a: Develop a definition & baseline number of agency/professional partnerships
that address community health
• FY 09 1.6a: Develop a baseline for the amount of direct funding to school and
community organizations
• FY 09 1.7a: Develop a baseline partnership effectiveness rating for Cherokee Nation
Community Health Programs
Health Outcomes for Cherokee Communities:
Health Outcomes represent the effect on health status from performance of one or more
processes or activities carried out by healthcare providers. Health outcomes include
morbidity and mortality; physical, social, and mental functioning; nutritional status; and
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 20 of 48
quality of life. Cherokee Nation Health Services provides high-quality health care and services
in accordance with the principles of professional practice and ethical conduct, and with
concern for the costs of care and improving community health status. Improving health
outcomes continues to be a core function and is monitored via Cherokee Nation Health
Services Quality Improvement. As described earlier in this document (see Quality
Improvement and Performance Monitoring - Methodology) we monitor quarterly indicators
such as hypertension control, tobacco abuse, immunization and screening rates. Government
Performance Results Act (GPRA) indicators and Diabetes Care audits are two of the major
sources of outcome data. While our selected GPRA indicators and the Diabetes audits
continue, we have selected several outcome indicators for increased focus. Throughout 2008
Cherokee Nation Health Services has been participating in a pilot project with the Indian
Health Service to implement Innovations in Planned Care (IPC). The IPC initiative aims to
reduce the impact and prevalence of chronic conditions such as diabetes, depression, asthma,
heart disease, and cancer. The Indian Health Service has developed a partnership with the
Institute for Healthcare Improvement (IHI) to use modern improvement methodologies to
fundamentally transform our system of care for clinical prevention and for the management
of chronic conditions. The ideas that guide this transformation come from the Chronic Care
Model (Care Model), developed at the MacColl Institute for Healthcare Innovation, adopted
by the World Health Organization and tested and implemented widely in the U.S. and abroad.
The Cherokee Nation IPC pilot site has already begun to show remarkable increases in rates of
screening for cancer, domestic violence, and alcohol misuse in the provision of
comprehensive diabetes care, blood pressure control, and in the management of other
chronic conditions. Just as importantly, they are showing reductions in wait time, improved
access and continuity of care, and the development of a truly functional, proactive and
prepared care team. The 2009 Health Outcome objectives devote a significant amount of
effort to establishing the foundation for implementation of the IPC project in all our health
facilities by 2013. These objectives include:
• FY 09 2.1a: Determine baseline for intake screening bundle rates for each facility
• FY 09 2.2a: Determine baseline cancer screening bundle rates for each facility
• FY 09 2.3a: Increase childhood immunization rates for 0-27 months
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 21 of 48
• FY 09 2.3b: Increase childhood immunization rates for 19-36 months
• FY 09 2.4a: Determine baseline control of blood pressure rates for each facility
• FY 09 2.5a: Determine baseline control of lipids rates for each facility
• FY 09 2.6a: Determine baseline Diabetes comprehensive care rates for each facility
• FY 09 2.7a: Determine baseline nutrition and exercise education rates for at risk
populations for each facility
• FY 09 2.8a: Determine baseline % of patients with self-management goals for each
facility
• FY 09 2.9a: Determine baseline % of patients who report confidence in ability to
manage health for each facility
Public Health Infrastructure:
Cherokee Nation Health Services remains a leader among Tribes in building, maintaining, and
strengthening our public health infrastructure. We were the first Tribe to implement our own
Institutional Review Board with Federal-Wide Assurance and Registration and continue to
develop and expand research partnerships with University of Oklahoma as well as other
research organizations.
To protect and promote the public's health our public health infrastructure must be strong.
Infrastructure can be thought of as all the parts within the public health system that work to
help health professionals carry out the essential public health services. Cherokee Nation is
working to develop and expand these services such a monitoring health status to identify
community health problems, diagnosing and investigating health problems and health
hazards in the community, informing, educating, and empowering people about health
issues, developing policies and plans that support individual and community health efforts
and researching for new insights and innovative solutions to health problems.
Cherokee Nation strives to meet local, state, and national standards in all areas and public
health infrastructure is no exception. A new initiative for 2009 is the process of preparing
Cherokee Nation for a voluntary national accreditation program that will help our public
health program assess its current capacity and guide us to become even better providers of
quality service, thus promoting a healthier public. Benefits of accreditation include high
performance and quality improvement, recognition and validation of the public health
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 22 of 48
program’s work, and improved access to resources. Preparation for voluntary accreditation is
expected to take three to four years. 2009 Public Health Infrastructure objectives include
specific objectives related to this process and are as follows:
• FY 09 3.1a: Complete NACCHO2 Self-Assessment Improvement Plan
• FY 09 3.1b: Develop a written plan to monitor health status in the Cherokee Nation
according to National Public Health Performance Standards
• FY 09 3.1c: Develop a written plan for health policy development in the Cherokee
Nation according to National Public Health Performance Standards
Access to Services:
Cherokee Nation works to ensure accessible and available health services, appropriate and
timely referrals and consultation, and provides a reliable process for accessing appropriate
care. In addition to clinical health services, we work to provide access to service within our
communities to promote prevention activities. The 2009 objectives for Access to Services also
includes work to increase access to contract health specialty services, health promotion
opportunities, and a significant focus on implementation of the Innovations in Planned Care
(IPC)project as previously described in the Health Outcomes section. The 2009 Access to
Services objectives include:
• FY 09 4.1a: Ensure access to community health promotion activities at Three Rivers
Health Center
• FY 09 4.2a Increase access to Behavioral Health Clinical Services via ATR
• FY 09 4.4a: Improve annual census rate for Jack Brown Adolescent Treatment Center
• FY 09 4.5a: Develop the CHS specialty services plan
• FY 09 4.6a: Revise the Health Services Capital Improvement Plan
• FY 09 4.7a: Complete IPC Orientation Process
• FY 09 4.7b: Form Care Teams for all primary care providers
• FY 09 4.7c: RN Care Managers at each facility will run the monthly IPC report for each of
their designated Care Teams and post monthly reports in patient and employee areas
2 NACCHO is National Association of City and County Health Officials
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 23 of 48
• FY 09 4.7e: Complete the specified assessment tools from the Dartmouth “Green Book”:
"Patient Cycle Tool “, “Know Your Processes”, & “Through the Eyes of Your Patients”
• FY 09 4.7f: Conduct at least one multi-departmental improvement project on a
problem identified using one of the Green Book assessment tools
Resource Management:
In the federal funding categories, Indian health funding is classified as a discretionary
program as opposed to an entitlement program. Entitlement programs such as Medicare and
Medicaid receive funding increases as the eligible population increases. Because of this
designation the Cherokee Nation receives very conservative funding increases that do not
meet either of the key factors leading to increasing costs - the increasing population and
medical inflation. Due to this severe under-funding by the federal government the Cherokee
Nation must manage the available resources provided to us with the utmost efficiency.
Increasing receipts of third party funding from private insurance, Medicare and Medicaid,
expanding programs and services through grant funding, and aggressively managing the
costs of doing business on a daily basis allows the Cherokee Nation to provide the best
quality services to the population. Resource Management objectives for 2009 include:
• FY 09 5.1a: Establish an internal review process made up of Health Group Strategic
Work Team members for purposes of reviewing/editing submittals to meet established
criteria and track the # of proposal reviewed and submitted to SBC
• FY 09 5.1b: Develop a 2009 Health Group SBC preparation calendar establishing
timelines to accommodate proposal preparation, internal review and final submission
and distribute to program management
• FY 09 5.2a: Increase third-party revenue by 5% over FY-08 collections:
(Baseline$17,397,415)
• FY 09 5.3a: Increase the number of new grants by 2
Health Industry Business Leadership:
The goal for Cherokee Nation Health in Health Industry Business Leadership is to strengthen
health industry business partnerships in Cherokee Nation. The objective for 2009 is to
complete the regional leadership plan for health services initiated in 2008.
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 24 of 48
The Health Regional Leadership Plan will describe specific objectives for growing and
strengthening the health industry cluster and will define Cherokee Nation's role in this
growth strategy. Cherokee Nation Health Services has made many accomplishments thus far,
but this plan will reaffirm our role as a leader in regional health care, including partnerships
with other health facilities, strategic location of facilities and services, targeted health industry
trainings, and research partnerships. By definition, an industry cluster is a geographic
concentration of competing, complementary, or interdependent firms and industries that do
business with each other and/or have common needs for worker skills, technology, markets,
infrastructure, and other economic resources. The firms and institutions included in a cluster
may be both competitive and cooperative. They may compete directly with some members
of the cluster, purchase inputs from other cluster members, and rely on the services of other
cluster firms in the operation of their business. A key ingredient to building any industry
cluster is research and the strides you make in the targeted area will play a vital role in further
development.
Operational Efficiency:
An effective and efficient health care organization searches for ways to reduce costs, improve
the quality of care, and meet stringent guidelines. Cherokee Nation Health is continuously
seeking creative methods of service delivery that enhance our capacity. Organizational
operations include information systems, process management, human resource
management, and the leadership system. Operational Efficiency objectives for 2009 include:
• FY 09 7.1a: Finalize and develop implementation schedule for long range plan for JBC,
BHS, HPDP, & EMS
• FY 09 7.1b: Initiate development of long range plan for PHN and WIC
• FY 09 7.2a: Develop and begin implementation activities for Health Services
Communications Plan
• FY 09 7.3a: Maintain accreditation and/or program recognition for health programs
• FY 09 7.4a: Improve organizational performance via annual process improvement goals
for each program
• FY 09 7.5a: Achieve a customer satisfaction rate of 85 % or above
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 25 of 48
Cherokee Workforce Development:
Cherokee Nation Health recognizes the importance of building and maintaining a skilled,
competent, and highly trained workforce. We strive to increase employee job satisfaction and
provide employees with relevant training opportunities. During 2009 we will focus on several
areas including enhancing the planning skills of employees as well as training related to
fostering Cherokee Nation priorities including mutual contribution strategy and process
evaluation. The 2009 Cherokee Workforce Development objectives include:
• FY 09 8.1a: Achieve and maintain an employee job satisfaction rate of 85 % or above
• FY 09 8.2a: Develop methodology and determine baseline for health professionals’
vacancy rate
• FY 09 8.3a: Develop methodology and determine baseline for health professionals’
retention rate
• FY 09 8.4a: Develop a written management succession plan for each
program/department at the director level
• FY 09 8.5a: Maintain the % of health services group employees who are American
Indian or Cherokee Nation Citizens (Baseline: 87.6%)
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 26 of 48
2009 BALANCED SCORECARDS:
OVERALL HEALTH SERVICES SCORECARD
DIRECT CARE SCORECARDS
CLINICAL SUPPORT SCORECARDS
COMMUNITY HEALTH SCORECARDS
ADMINISTRATIVE SUPPORT SCORECARDS
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 27 of 48
Priority 2009 Objective Measure 2009 Target 2013 TargetCommunity-Based FY 09 1.1a: Develop a written process for
conducting community health assessmentsWritten Process Complete 10 community
health improvement
plans
Community-Based FY 09 1.2a: Develop a written plan for a Community Health Surveillance System
Written Plan Complete 11 community health
improvement plans
Community-Based FY 09 1.3a: Develop a definition & baseline number of community partnerships
Baseline developed
Complete ↑ community partnerships
Community-Based FY 09 1.4a: Develop a definition & baseline number of school partnerships
Baseline developed
Complete ↑ school partnerships
Community-Based FY 09 1.5a: Develop a definition & baseline number of agency/professional partnerships that address community health
Baseline developed
Complete ↑ agency partnerships
Community-Based FY 09 1.6a: Develop a baseline for the amount of direct funding to school and community organizations
Baseline developed
Complete ↑ direct funding
Community-Based FY 09 1.7a: Develop a baseline partnership effectiveness rating for Cherokee Nation Community Health Programs
Baseline developed
Complete 75% Effectiveness
Rate
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
HEALTH SERVICES GROUPContact: Melissa Gower
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 28 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
HEALTH SERVICES GROUPContact: Melissa Gower
Health Outcomes FY 09 2.1a: Determine baseline for intake screening bundle rates for each facility
Baseline developed
Complete 70% Bundle Rates
Health Outcomes FY 09 2.2a: Determine baseline cancer screening bundle rates for each facility
Baseline developed
Complete 70% Bundle Rates
Health Outcomes FY 09 2.3a: Increase childhood immunization rates for 0-27 months
92% 100% 100%
Health Outcomes FY 09 2.3b: Increase childhood immunization rates for 19-36 months
95% 100% 100%
Health Outcomes FY 09 2.4a: Determine baseline control of blood pressure rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.5a: Determine baseline control of lipids rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.6a: Determine baseline Diabetes comprehensive care rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.7a: Determine baseline nutrition and exercise education rates for at risk populations for each facility
Baseline developed
Complete 60%
Health Outcomes FY 09 2.8a: Determine baseline % of patients with self-management goals for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.9a: Determine baseline % of patients who report confidence in ability to manage health for each facility
Baseline developed
Complete 90%
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 29 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
HEALTH SERVICES GROUPContact: Melissa Gower
Public Health Infrastructure FY 09 3.1a: Complete NACCHO Self-Assessment Improvement Plan
Improvement Plan Complete
Complete NACCHO Accreditation
Public Health Infrastructure FY 09 3.1b: Develop a written plan to monitor health status in the Cherokee Nation according to National Public Health Performance Standards
Improvement Plan Complete
Complete NACCHO Accreditation
Public Health Infrastructure FY 09 3.1c: Develop a written plan for health policy development in the Cherokee Nation according to National Public Health Performance Standards
Improvement Plan Complete
Complete NACCHO Accreditation
Access to Services FY 09 4.1a: Ensure access to community health promotion activities at Three Rivers Health Center
Prevention activities offered
Complete Prevention activities within 30
miles of all CN citizens
Access to Services FY 09 4.2a Increase access to Behavioral Health Clinical Services via ATR
# of clients entered in the SAIS system
1,320 clients TBD
Access to Services FY 09 4.4a: Improve annual census rate for Jack Brown Adolescent Treatment Center
Annual Census Rate
5% Increase 20% Increase
Access to Services FY 09 4.5a: Develop the CHS specialty services plan
Plan Developed Complete Plan Fully Implemented
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 30 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
HEALTH SERVICES GROUPContact: Melissa Gower
Access to Services FY 09 4.6a: Revise the Health Services Capital Improvement Plan
Complete Complete Health
Services Capital
Improvement Plan
Access to Services FY 09 4.7a: Complete Planned Care Orientation Process
Orientation Process at each facility
Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7b: Form Care Teams for all primary care providers.
Teams Formed Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7c: RN Care Managers at each facility will run the monthly Planned Care report for each of their designated Care Teams and post monthly reports in patient and employee areas
Monthly reports beginning in January 09
Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7e: Complete the specified assessment tools from the Dartmouth “Green Book”: "Patient Cycle Tool “(Tool – 11 on pg. 17)“Know Your Processes” – (Tool 12 on pg. 19)“Through the Eyes of Your Patients” – (Tool 14 on pg. 23)
Assessment tools complete
Complete Implement Planned Care at all facilities
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 31 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
HEALTH SERVICES GROUPContact: Melissa Gower
Access to Services FY 09 4.7f: Conduct at least one multi-departmental improvement project on a problem identified using one of the Green Book assessment tools.
1 project at each facility
Complete Implement Planned Care at all facilities
Resource Management FY 09 5.1a: Establish an internal review process made up of Health Group Strategic Work Team members for purposes of reviewing/editing submittals to meet established criteria and track the # of proposal reviewed and submitted to SBC
Process Complete
Complete ↑Health Services SBC
funding
Resource Management FY 09 5.1b: Develop a 2009 Health Group SBC preparation calendar establishing timelines to accommodate proposal preparation, internal review and final submission and distribute to program management.
Calendar Disseminated
Complete ↑ Health Services SBC
funding
Resource Management FY 09 5.2a: Increase third-party revenue by 5% over FY-08 collections: (Baseline$17,397,415)
↑ 5% ↑ 5% ↑25% above FY 2008
Resource Management FY 09 5.3a: Increase the number of new grants by 2
2 new grants 2 new grants 10 new Health Services Grants
Regional Leadership FY 09 6.1a: Complete regional leadership plan for health services
Plan Developed Complete Plan Implemented
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 32 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
HEALTH SERVICES GROUPContact: Melissa Gower
Access to Services FY 09 4.6a: Revise the Health Services Capital Improvement Plan
Plan Revised Complete Complete Health
Services Capital
Improvement Plan
Access to Services FY 09 4.7a: Complete Planned Care Orientation Process
Orientation Process at each facility
Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7b: Form Care Teams for all primary care providers.
Teams Formed Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7c: RN Care Managers at each facility will run the monthly Planned Care report for each of their designated Care Teams and post monthly reports in patient and employee areas
Monthly reports beginning in January 09
Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7e: Complete the specified assessment tools from the Dartmouth “Green Book”: "Patient Cycle Tool “(Tool – 11 on pg. 17)“Know Your Processes” – (Tool 12 on pg. 19)“Through the Eyes of Your Patients” – (Tool 14 on pg. 23)
Assessment tools complete
Complete Implement Planned Care at all facilities
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 33 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
HEALTH SERVICES GROUPContact: Melissa Gower
Cherokee Workforce FY 09 8.2a: Develop methodology and determine baseline for health professionals vacancy rate
Baseline & methodology developed
Complete ↓ health professionals vacancy rate
Cherokee Workforce FY 09 8.3a: Develop methodology and determine baseline for health professionals retention rate
Baseline & methodology developed
Complete ↑ health professionals retention rate
Cherokee Workforce FY 09 8.4a: Develop a written management succession plan for each program/department at the director level
Written plan at director level
Complete Written succession plan at all
levelsCherokee Workforce FY 09 8.5a: Maintain the % of health services
group employees who are American Indian or Cherokee Nation Citizens (Baseline: 87.6%)
Maintain % Maintain % ↑%
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 34 of 48
Priority 2009 Objective Measure 2009 Target 2013 TargetHealth Outcomes FY 09 2.1a: Determine baseline for intake
screening bundle rates for each facilityBaseline developed
Complete 70% Bundle Rates
Health Outcomes FY 09 2.2a: Determine baseline cancer screening bundle rates for each facility
Baseline developed
Complete 70% Bundle Rates
Health Outcomes FY 09 2.3a: Increase childhood immunization rates for 0-27 months
92% 100% 100%
Health Outcomes FY 09 2.3b: Increase childhood immunization rates for 19-36 months
95% 100% 100%
Health Outcomes FY 09 2.4a: Determine baseline control of blood pressure rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.5a: Determine baseline control of lipids rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.6a: Determine baseline Diabetes comprehensive care rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.7a: Determine baseline nutrition and exercise education rates for at risk populations for each facility
Baseline developed
Complete 60%
Health Outcomes FY 09 2.8a: Determine baseline % of patients with self-management goals for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.9a: Determine baseline % of patients who report confidence in ability to manage health for each facility
Baseline developed
Complete 90%
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
DIRECT CAREOwner: Mike Pruitt and Rhonda Cochran
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 35 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
DIRECT CAREOwner: Mike Pruitt and Rhonda Cochran
Access to Services FY 09 4.2a Increase access to Behavioral Health Clinical Services via ATR
# of clients entered in the SAIS system
1,320 clients TBD
Access to Services FY 09 4.7a: Complete Planned Care Orientation Process
Orientation Process at each facility
Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7b: Form Care Teams for all primary care providers.
Teams Formed Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7c: RN Care Managers at each facility will run the monthly Planned Care report for each of their designated Care Teams and post monthly reports in patient and employee areas
Monthly reports beginning in January 09
Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7e: Complete the specified assessment tools from the Dartmouth “Green Book”: "Patient Cycle Tool “(Tool – 11 on pg. 17)“Know Your Processes” – (Tool 12 on pg. 19)“Through the Eyes of Your Patients” – (Tool 14 on pg. 23)
Assessment tools complete
Complete Implement Planned Care at all facilities
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 36 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
DIRECT CAREOwner: Mike Pruitt and Rhonda Cochran
Access to Services FY 09 4.7f: Conduct at least one multi-departmental improvement project on a problem identified using one of the Green Book assessment tools.
1 project at each facility
Complete Implement Planned Care at all facilities
Resource Management FY 09 5.2a: Increase third-party revenue by 5% over FY-08 collections: (Baseline$17,397,415)
↑ 5% ↑ 5% ↑25% above FY 2008
Organizational Efficiency FY 09 7.3a: Maintain accreditation and/or program recognition for health programs
Maintain Accreditation
Accreditation Maintained
Accreditation Maintained &
NACCHO obtained
Organizational Efficiency FY 09 7.5a: Achieve a customer satisfaction rate of 85 % or above
85% 85% 85%
Cherokee Workforce FY 09 8.1a: Achieve and maintain an employee job satisfaction rate of 85 % or above
85% 85% 85%
Cherokee Workforce FY 09 8.2a: Develop methodology and determine baseline for health professionals vacancy rate
Baseline & methodology developed
Complete ↓ health professionals vacancy rate
Cherokee Workforce FY 09 8.5a: Maintain the % of health services group employees who are American Indian or Cherokee Nation Citizens (Baseline: 87.6%)
Maintain % Maintain % ↑%
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 37 of 48
Priority 2009 Objective Measure 2009 Target 2013 TargetHealth Outcomes FY 09 2.1a: Determine baseline for intake
screening bundle rates for each facilityBaseline developed
Complete 70% Bundle Rates
Health Outcomes FY 09 2.2a: Determine baseline cancer screening bundle rates for each facility
Baseline developed
Complete 70% Bundle Rates
Health Outcomes FY 09 2.3a: Increase childhood immunization rates for 0-27 months
92% 100% 100%
Health Outcomes FY 09 2.3b: Increase childhood immunization rates for 19-36 months
95% 100% 100%
Health Outcomes FY 09 2.4a: Determine baseline control of blood pressure rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.5a: Determine baseline control of lipids rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.6a: Determine baseline Diabetes comprehensive care rates for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.7a: Determine baseline nutrition and exercise education rates for at risk populations for each facility
Baseline developed
Complete 60%
Health Outcomes FY 09 2.8a: Determine baseline % of patients with self-management goals for each facility
Baseline developed
Complete 70%
Health Outcomes FY 09 2.9a: Determine baseline % of patients who report confidence in ability to manage health for each facility
Baseline developed
Complete 90%
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
CLINICAL SUPPORTOWNER: Gloria Grim, M.D., F.A.A.F.P.
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 38 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
CLINICAL SUPPORTOWNER: Gloria Grim, M.D., F.A.A.F.P.
Public Health Infrastructure FY 09 3.1b: Develop a written plan to monitor health status in the Cherokee Nation according to National Public Health Performance Standards
Improvement Plan Complete
Complete NACCHO Accreditation
Access to Services FY 09 4.2a Increase access to Behavioral Health Clinical Services via ATR
# of clients entered in the SAIS system
1,320 clients TBD
Access to Services FY 09 4.5a: Develop the CHS specialty services plan
Plan Developed Complete Plan Fully Implemented
Access to Services FY 09 4.7a: Complete Planned Care Orientation Process
Orientation Process at each facility
Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7b: Form Care Teams for all primary care providers.
Teams Formed Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7c: RN Care Managers at each facility will run the monthly Planned Care report for each of their designated Care Teams and post monthly reports in patient and employee areas
Monthly reports beginning in January 09
Complete Implement Planned Care at all facilities
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 39 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
CLINICAL SUPPORTOWNER: Gloria Grim, M.D., F.A.A.F.P.
Access to Services FY 09 4.7e: Complete the specified assessment tools from the Dartmouth “Green Book”: "Patient Cycle Tool “(Tool – 11 on pg. 17)“Know Your Processes” – (Tool 12 on pg. 19)“Through the Eyes of Your Patients” – (Tool 14 on pg. 23)
Assessment tools complete
Complete Implement Planned Care at all facilities
Access to Services FY 09 4.7f: Conduct at least one multi-departmental improvement project on a problem identified using one of the Green Book assessment tools.
1 project at each facility
Complete Implement Planned Care at all facilities
Resource Management FY 09 5.2a: Increase third-party revenue by 5% over FY-08 collections: (Baseline$17,397,415)
↑ 5% ↑ 5% ↑25% above FY 2008
Resource Management FY 09 5.3a: Increase the number of new grants by 2
2 new grants 2 new grants 10 new Health Services Grants
Regional Leadership FY 09 6.1a: Complete regional leadership plan for health services
Plan Developed Complete Plan Implemented
Organizational Efficiency FY 09 7.1b: Initiate development of long range plan for PHN and WIC
Initiate Plan Development Process
Process Initiated
Long Range Plan for all
Health programs
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 40 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
CLINICAL SUPPORTOWNER: Gloria Grim, M.D., F.A.A.F.P.
Organizational Efficiency FY 09 7.3a: Maintain accreditation and/or program recognition for health programs
Maintain Accreditation
Accreditation Maintained
Accreditation Maintained &
NACCHO obtained
Organizational Efficiency FY 09 7.4a: Improve organizational performance via annual process improvement goals for each program
# of programs with documented and tracked goals
All programs Annual goal each year for
every program
Organizational Efficiency FY 09 7.5a: Achieve a customer satisfaction rate of 85 % or above
85% 85% 85%
Cherokee Workforce FY 09 8.1a: Achieve and maintain an employee job satisfaction rate of 85 % or above
85% 85% 85%
Cherokee Workforce FY 09 8.2a: Develop methodology and determine baseline for health professionals vacancy rate
Baseline & methodology developed
Complete ↓ health professionals vacancy rate
Cherokee Workforce FY 09 8.3a: Develop methodology and determine baseline for health professionals retention rate
Baseline & methodology developed
Complete ↑ health professionals retention rate
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 41 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
CLINICAL SUPPORTOWNER: Gloria Grim, M.D., F.A.A.F.P.
Cherokee Workforce FY 09 8.4a: Develop a written management succession plan for each program/department at the director level
Written plan at director level
Complete Written succession plan at all
levelsCherokee Workforce FY 09 8.5a: Maintain the % of health services
group employees who are American Indian or Cherokee Nation Citizens (Baseline: 87.6%)
Maintain % Maintain % ↑%
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 42 of 48
Priority 2009 Objective Measure 2009 Target 2013 TargetCommunity-Based FY 09 1.1a: Develop a written process for
conducting community health assessmentsWritten Process Complete 10 community
health improvement
plans
Community-Based FY 09 1.2a: Develop a written plan for a Community Health Surveillance System
Written Plan Complete 11 community health
improvement plans
Community-Based FY 09 1.3a: Develop a definition & baseline number of community partnerships
Baseline developed
Complete ↑ community partnerships
Community-Based FY 09 1.4a: Develop a definition & baseline number of school partnerships
Baseline developed
Complete ↑ school partnerships
Community-Based FY 09 1.5a: Develop a definition & baseline number of agency/professional partnerships that address community health
Baseline developed
Complete ↑ agency partnerships
Community-Based FY 09 1.6a: Develop a baseline for the amount of direct funding to school and community organizations
Baseline developed
Complete ↑ direct funding
Community-Based FY 09 1.7a: Develop a baseline partnership effectiveness rating for Cherokee Nation Community Health Programs
Baseline developed
Complete 75% Effectiveness
Rate
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
COMMUNITY HEALTHContact: Melissa Gower
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 43 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
COMMUNITY HEALTHContact: Melissa Gower
Public Health Infrastructure FY 09 3.1a: Complete NACCHO Self-Assessment Improvement Plan
Improvement Plan Complete
Complete NACCHO Accreditation
Public Health Infrastructure FY 09 3.1b: Develop a written plan to monitor health status in the Cherokee Nation according to National Public Health Performance Standards
Improvement Plan Complete
Complete NACCHO Accreditation
Public Health Infrastructure FY 09 3.1c: Develop a written plan for health policy development in the Cherokee Nation according to National Public Health Performance Standards
Improvement Plan Complete
Complete NACCHO Accreditation
Access to Services FY 09 4.1a: Ensure access to community health promotion activities at Three Rivers Health Center
Prevention activities offered
Complete Prevention activities within 30
miles of all CN citizens
Access to Services FY 09 4.2a Increase access to Behavioral Health Clinical Services via ATR
# of clients entered in the SAIS system
1,320 clients TBD
Access to Services FY 09 4.4a: Improve annual census rate for Jack Brown Adolescent Treatment Center
Annual Census Rate
5% Increase 20% Increase
Resource Management FY 09 5.2a: Increase third-party revenue by 5% over FY-08 collections: (Baseline$17,397,415)
↑ 5% ↑ 5% ↑25% above FY 2008
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 44 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
COMMUNITY HEALTHContact: Melissa Gower
Resource Management FY 09 5.3a: Increase the number of new grants by 2
2 new grants 2 new grants 10 new Health Services Grants
Organizational Efficiency FY 09 7.1a: Finalize and develop implementation schedule for long range plan for JBC, BHS, HPDP, & EMS
Plan Developed and Implemented
Complete Long Range Plan for all
Health programs
Organizational Efficiency FY 09 7.3a: Maintain accreditation and/or program recognition for health programs
Maintain Accreditation
Accreditation Maintained
Accreditation Maintained &
NACCHO obtained
Organizational Efficiency FY 09 7.4a: Improve organizational performance via annual process improvement goals for each program
# of programs with documented and tracked goals
All programs Annual goal each year for
every program
Organizational Efficiency FY 09 7.5a: Achieve a customer satisfaction rate of 85 % or above
85% 85% 85%
Cherokee Workforce FY 09 8.1a: Achieve and maintain an employee job satisfaction rate of 85 % or above
85% 85% 85%
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 45 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
COMMUNITY HEALTHContact: Melissa Gower
Cherokee Workforce FY 09 8.4a: Develop a written management succession plan for each program/department at the director level
Written plan at director level
Complete Written succession plan at all
levelsCherokee Workforce FY 09 8.5a: Maintain the % of health services
group employees who are American Indian or Cherokee Nation Citizens (Baseline: 87.6%)
Maintain % Maintain % ↑%
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 46 of 48
Priority 2009 Objective Measure 2009 Target 2013 TargetAccess to Services FY 09 4.6a: Revise the Health Services Capital
Improvement PlanComplete Complete
Health Services Capital
Improvement Plan
Resource Management FY 09 5.1a: Establish an internal review process made up of Health Group Strategic Work Team members for purposes of reviewing/editing submittals to meet established criteria and track the # of proposal reviewed and submitted to SBC
Process Complete
Complete ↑Health Services SBC
funding
Resource Management FY 09 5.1b: Develop a 2009 Health Group SBC preparation calendar establishing timelines to accommodate proposal preparation, internal review and final submission and distribute to program management.
Calendar Disseminated
Complete ↑ Health Services SBC
funding
Resource Management FY 09 5.2a: Increase third-party revenue by 5% over FY-08 collections: (Baseline$17,397,415)
↑ 5% ↑ 5% ↑25% above FY 2008
Resource Management FY 09 5.3a: Increase the number of new grants by 2
2 new grants 2 new grants 10 new Health Services Grants
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
ADMINISTRATIVE SUPPORTContact: Rick Kelly
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 47 of 48
Priority 2009 Objective Measure 2009 Target 2013 Target
Cherokee Nation Health ServicesFY 2009 Balanced Scorecard
ADMINISTRATIVE SUPPORTContact: Rick Kelly
Regional Leadership FY 09 6.1a: Complete regional leadership plan for health services
Plan Developed Complete Plan Implemented
Organizational Efficiency FY 09 7.4a: Improve organizational performance via annual process improvement goals for each program
# of programs with documented and tracked goals
All programs Annual goal each year for
every program
Organizational Efficiency FY 09 7.5a: Achieve a customer satisfaction rate of 85 % or above
85% 85% 85%
Cherokee Workforce FY 09 8.1a: Achieve and maintain an employee job satisfaction rate of 85 % or above
85% 85% 85%
Cherokee Workforce FY 09 8.4a: Develop a written management succession plan for each program/department at the director level
Written plan at director level
Complete Written succession plan at all
levelsCherokee Workforce FY 09 8.5a: Maintain the % of health services
group employees who are American Indian or Cherokee Nation Citizens (Baseline: 87.6%)
Maintain % Maintain % ↑%
Appendix B: Cherokee Nation Health Services 2009 Quality Improvement Plan Page 48 of 48